Trichotillomania

Trichotillomania (hair pulling disorder) is recurrent pulling out of one's hair resulting in hair loss, with repeated attempts to stop.

• Prevalence 1 to 2%; onset at 10 to 13 years; women more commonly present.
• Focused (conscious, tension relief) and automatic (unaware) types.
• Comorbid anxiety, depression, OCD, skin picking, ADHD.
• Complications: bald patches, trichobezoar (Rapunzel syndrome) with intestinal obstruction, social avoidance.

• Hair pulling from scalp, eyebrows, eyelashes, pubic area; tension before and relief after; chewing or eating hair (trichophagia).
• Patchy irregular hair loss with broken hairs of varying length; camouflaging using wigs, makeup.
• Shame and secrecy.

• Clinical interview; Massachusetts General Hospital Hairpulling Scale.
• Dermoscopy: broken hairs, black dots, trichoscopic "flame hairs"; biopsy only if uncertain (empty follicles, trichomalacia, pigment casts).
• Exclude alopecia areata, tinea capitis, telogen effluvium, traction alopecia.
• Examine for trichobezoar if abdominal pain or vomiting; assess comorbid psychiatric illness.

• Habit reversal training (awareness training, competing response, stimulus control; 8 to 12 sessions) and full behavioural model (ComB) are first line.
• Medication: N-acetylcysteine 1200 to 2400 mg daily (benefit in adults), olanzapine 2.5 to 10 mg, clomipramine 100 to 250 mg, SSRIs have limited effect unless comorbid anxiety or depression; naltrexone 50 mg trial.
• Barriers: gloves, scalp covering, fidgets.
• Trichobezoar: endoscopic or surgical removal.
• Treat comorbid conditions; support groups.